Provider Demographics
NPI:1841056181
Name:HUERTA, JUAN MANUEL
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:MANUEL
Last Name:HUERTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9115 W CERMAK RD APT 10
Mailing Address - Street 2:
Mailing Address - City:NORTH RIVERSIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60546-1097
Mailing Address - Country:US
Mailing Address - Phone:708-426-9441
Mailing Address - Fax:
Practice Address - Street 1:5909 W 35TH ST
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:IL
Practice Address - Zip Code:60804-4163
Practice Address - Country:US
Practice Address - Phone:708-652-2040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-26
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042.618499207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine